Strategies for Nurse Managers, April 2009

CLICK to Email E-mail
CLICK for Print Version Print
CLICK for PDF Version PDF



Facility’s homegrown HIPAA video entertains and educates staff members

Build up nursing research collaboration with a database

Oral care helps facilities wash out VAP rates

When colleagues clash

Celebrate the image of nursing

Enhanced system assessments improve patient flow

Hospital offers helping HAND

Mesh your facility’s mission statement with its culture




Facility’s homegrown HIPAA video entertains and educates staff members

Mandatory HIPAA training is usually met by staff members with the same excitement as a trip to the dentist. Sure, they have to do it, but they don’t have to like it.

Diane Adams, director of training and education at The Mount Sinai Medical Center in New York City, wasn’t satisfied with that response to training she knew was vitally important to everyone’s jobs.

Her team of trainers and administration staff members thought getting behind—and in front of—the camera to infuse humor into an otherwise dry training video would net positive results.

But Adams could not have imagined how popular the video would become. Since 2006, excitement and laughs over the video have created such a buzz that the demand for more specific training videos still stream in today, transforming her department into a pseudo–Universal Studios. “Videos are really the hot new thing, but they are not an easy thing to produce,” Adams says. “There’s a thin line between funny and eye rolling, so it takes a lot of time to get it right.”

But the department’s first video, HIPAA @ Sinai, is an example of how effective a humorous, for-staff, by-staff video can be when the pieces fall into place.

Filming to meet staff members’ needs

Adams has worked for Mount Sinai for 17 years; the past four as the director of training and education.

When she joined the team, the department used a combined approach to HIPAA training, featuring one-on-one sessions, PowerPoint training, and a HIPAA video produced by an outside vendor.

Although the video was straightforward and informative, it didn’t excite its audience.

But that alone wasn’t enough justification to produce a new video. Regulatory changes, such as the release of the final security rule, eventually rendered the old video obsolete.

The training department decided that a similar video produced outside the facility would miss an opportunity to make the training fun, memorable, and therefore effective.

Working behind the scenes

Because Adams and her staff members didn’t have a Titanic-like budget to produce a video, they cut corners by maximizing the talents of their department and other hospital staff members.

The department already had a handheld camera. They recruited actors from the hospital staff—nearly 60 people participated in the final product—and worked with staff management to find appropriate times for staff members to participate in the video without disrupting their work flow. That meant spreading the shooting of the video over six months, instead of six weeks.

At the start, staff members met with Aviva Halpert, Mount Sinai’s chief HIPAA officer, to brainstorm video content. After this was incorporated into the script, Adams says Halpert reviewed it and discussed what was wrong and what was accurate with staff members.

The creative brain behind the video was one of Adams’ trainers, Steve Fecteau, who narrated and acted in the video.

The team shot the video at the hospital, using a closed area that was under construction for much of the filming.

Portraying information creatively

The video begins with Fecteau sitting at a computer, introducing himself and the purpose of the training. Moments later, he bounces up from his chair to talk to actual hospital staff members about HIPAA challenges they face, but not before he reminds viewers that he almost forgot to lock his computer.

He briefly discusses HIPAA’s computer security requirement, but before the talk gets too technical—and boring for the viewer—he is running into the next scene. That’s one reason the video works well; it covers important information while keeping it fast, fresh, and funny.

“The humor is what makes the video so unique,” says Adams. “Sometimes, the audience can’t hear the second line because they are still laughing at the first one.”

The video also has brief cameos from staff members discussing how they come in contact with HIPAA in their jobs. The viewers hear from a nurse, building services member, security officer, catering worker, quality insurance nurse, and patient finance worker.

Another scene shows a staff member receiving pressure to divulge protected health information from a patient’s husband, sister, and former physician. It’s funny, but also paints a real picture of how to react to such a common occurrence.

Screening for staff members

Since the video premiered in 2006, Adams’ staff has shown it at least 200 more times to approximately 13,000 people.

But it’s no ordinary training session. Viewers are treated to bags of popcorn, references to a “show” as opposed to a “training program,” and Broadway music prior to the video starting.


Adapted from Briefings on HIPAA, February 2009, HCPro, Inc.




Build up nursing research collaboration with a database

After reading this article, you will be able to:

  • Identify the benefits of a nursing research database

The research director at Cleveland Clinic has successfully guided staff nurses through research projects with the help of tools and templates stored on the organization’s intranet. And more help is on the way, as the intranet is becoming a research database.

“The database will be a warehouse for current research projects in motion, as well as completed projects,” says Nancy Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM, director of nursing research and innovation at Cleveland Clinic. “It will save time, prevent redundancy, increase knowledge, and promote collaboration among different units.”

Staff nurses at Cleveland Clinic will have the ability to log in to the hospital’s intranet and discover a new world of research with the database. The project, which Albert and other nursing leaders at the facility developed, is slated to go live this year.

Nursing research can bring many benefits to the healthcare setting, as it promotes nurses’ individual growth and encourages the implementation of new care delivery techniques.

“The research database will be a valuable tool in helping staff nurses share project ideas and, more importantly, literature findings, which is always time-consuming for nurses,” says Terri Murray, RN, BSN, nurse manager.

The user-friendly database will allow nurses to quickly find what they are looking for, says Albert. For example, if a nurse is interested in conducting a study on improving blood flow in the lower legs when patients are on bed rest, he or she will log in to the database in search of similar studies or literature findings. When nurses log in, they will find:

  • Project status. Each project will have its own link detailing several items, including the status of the proposal, the point person, a timeline of the data collection, the due date, and approval by the institutional review board.
  • Topics. These are organized in many ways, including by patient population, research area, and nursing department. “By having multiple ways to access other research conducted in the past on the same topic in an efficient manner, nurses can learn what others are doing in our institution and collaborate with experts on a topic,” Albert says. “They can determine if they wish to replicate a previously conducted study and possibly save time in proposal writing and research startup.”

For example, the staff nurse conducting the research study on improving patient blood flow in the lower legs can see whether another staff member conducted the same study. If so, the nurse will be able to view the final research manuscript and obtain the researcher’s contact information.

That information can enhance the chances for success in a new project, as the new researcher can contact the original researcher to see what literature he or she found, issues that were encountered during data collection, aspects of research that went smoothly, and other potential contacts.

Although proposals will be available in the database, they will not be downloadable without permission.

“Having data that is visible to all viewers of the database saves investigator time and keeps management informed of current studies and progress,” says Albert. “Data that is not so readily transparent allows us to maintain confidentiality of ongoing research studies and encourages collaboration among different investigator teams.”



Adapted from HCPro’s Advisor to the ANCC Magnet Recognition Program®, February 2009, HCPro, Inc.



Infection control

Oral care helps facilities wash out VAP rates

After reading this article, you will be able to:

  • Describe oral care programs that helped two facilities lower ventilator-associated pneumonia (VAP) rates
  • Discuss strategies for educating staff members about VAP prevention processes

The Institute for Healthcare Improvement (IHI) states that VAP kills more patients every year than any other hospital-acquired infection (HAI), and 46% of those diagnosed with the condition die from it.

Once considered a likely outcome for patients put on ventilators, evidence-based practice has shown that with a few key steps, nursing practice can help reduce—if not eliminate—VAP at your hospital.

“Nurses are the gatekeepers for the patients. They protect them and they get things done,” says Carrie Sona, RN, MSN, CCNS, surgical critical care clinical nurse specialist at Barnes-Jewish Hospital (BJH) in St. Louis. “Success wouldn’t happen without nurses.”

Sona coauthored a yearlong study at BJH showing that oral care for patients on ventilators can help reduce incidents of VAP by at least 50%. Nurses at BJH brush patients’ teeth and apply mouthwash every 12 hours for patients on ventilators, preventing bacteria in the mouth from being aspirated and ending up in the lungs.

Before BJH started the study in 2004, the surgical/burn/trauma ICU had 5.2 cases of VAP per 1,000 ventilator days. At the end of the study, that number was reduced to 2.4 cases per 1,000 ventilator days. Today, it is down to 1.5 cases per 1,000 ventilator days.

A proven bundle, plus

BJH nurses followed VAP prevention guidelines issued by the Centers for Disease Control and Prevention (CDC) and the IHI before the hospital began its oral care research.

“Our goal has always been to get to zero,” says Lynn Schallom, RN, MSN, CCNS, coauthor of the BJH study and surgical critical care clinical nurse specialist. “And when our program wasn’t getting [the VAP rate] to zero, we asked, ‘What else can we do?’ We were following the CDC guidelines and pretty much doing all of the high-grade interventions. But there were other lower-level recommendations that we weren’t doing, and one of those was oral care.”

A multidisciplinary team of clinical staff members formed from the unit’s quality improvement group, including staff nurses, nurse managers, and physicians, decided that brushing teeth and using mouthwash was a fairly inexpensive but effective way to prevent bacteria buildup and give ventilator patients a better chance of avoiding the HAI.

Oral care’s effect on VAP rates has been studied before, but results have been inconclusive.

“Our infection control specialist and I went through a lot of oral care literature, and it’s very obvious that there has been quite the variance in practice. There was no standardized way of providing oral care,” Sona says.

Nurses at BJH now brush the teeth and rinse the mouths of patients on ventilators every 12 hours and document their practice.

A new routine

A strong focus on oral care was also critical to the reduction in VAP at Doylestown (PA) Hospital, says Tish Lawson, MSN, RN, clinical process improvement specialist at the 200-bed hospital. Using the IHI bundle (see the sidebar on p. 5), along with oral care and limited use of saline lavage, the hospital was able to bring its VAP rate down from 11.9 cases of VAP per 1,000 ventilator days in 2003 to 0.78 cases per 1,000 ventilator days at the end of 2008.

Asking already overstretched nurses to add more to their daily routine can sometimes be met with resistance, but at BJH and Doylestown, staff educators focused on each step in the prevention process and how it would keep patients safe.

“We put up a fairly large poster board that had all the steps clearly described and our expectation for the staff,” says Lawson, who was Doylestown’s educator at the time the new protocol was implemented. “We also brought in a speaker who gave a continuing education lecture about pneumonia itself, how it’s acquired in the hospital, and outlined steps for prevention.”

Documentation aided nurses in remembering each of the new steps. Nurses were required to document each step as it was completed, allowing nurse managers to provide feedback about how they were doing.

“When there is a process change, it is very difficult to remember the new process if the process changes are not hardwired,” Lawson says. “Providing them measurement of the process elements and the outcomes helps reinforce the changes.”

According to Lawson, the following items can assist facilities in shifting a long-held process:

  • A baseline measurement of the process you are trying to change.
  • A way to measure the progress of the process change.
  • Posted results and timely feedback to staff members.
  • Celebration of success when improvement milestones are reached.
  • Use of control charts to measure the process over time. Lawson says long-term results will keep natural variations from putting a negative spin on performance. Also, charts that show performance over time will allow you to easily see a drop in performance.

Weighing the evidence

Several studies from the late 1980s and early 1990s showed success in reducing cases of VAP with oral care for patients on ventilators. Although more recent studies haven’t been as conclusive, Lawson says, Doylestown decided to make oral care a key part of VAP prevention.

Another key for Doylestown was teaching its nursing staff to only suction ventilated patients when necessary, a step that was called a “sacred cow that should be put out to pasture” in an April 2008 Critical Care Nurse article. Other research has reinforced that use of saline lavage can introduce bacteria to the endotracheal tubes, priming the patient to develop VAP.

Spend a little, save a lot

Eliminating VAP is more than an issue of patient safety in hospitals. The cost of treating patients with VAP starts at $40,000, and although the Centers for Medicare & Medicaid Services hasn’t yet made it a no-pay condition, VAP has already been on the list of considered conditions twice.

The research committee at BJH calculated that providing oral care to patients in its surgical and trauma ICU costs less than $1 per day. Providing oral care every 12 hours cost the hospital approximately $2,200 during its study—small change when compared to the cost of treating a patient with VAP.

In addition, Schallom estimates that their oral care efforts saved their unit $27,000.


Rauen, C., et al (2008). “Seven Evidence-Based Practice Habits: Putting Some Sacred Cows Out to Pasture.” Critical Care Nurse 28 (2): 98–124.



Adapted from The Staff Educator, January 2009, HCPro, Inc.



Work environment

When colleagues clash

Effectively manage workplace conflict

After reading this article, you will be able to:

  • Identify techniques for managing workplace conflict
  • Recall potential sources of workplace conflict
  • Discuss challenges nurses have when resolving conflicts with physicians

In a healthcare facility, nurses, physicians, administrators, and other employees are likely to have a wide range of personalities.

With these staff members constantly communicating and interacting, there is a good chance there will also be conflict.

Nipping conflict in the bud is important to retaining the integrity of your facility, experts say.

“It’s like gangrene; it creates a toxic workplace,” says Kathleen Bartholomew, RC, RN, MN, author of the HCPro book Speak Your Truth: Proven Strategies for Effective Nurse-Physician Communication. “If you don’t deal with it, it spreads insidiously, and you can’t see the effects of it right away.”

The potential for conflict surrounds many issues in the healthcare setting.

Treatment disagreements, end-of-life patient care, discharge issues, orders not carried out correctly or in a timely manner, and simple pettiness among staff members all have the potential to create conflict.

Nurse managers must remember to act quickly when a staff conflict arises and have those involved meet, discuss the problem, and promptly resolve it.

“It’s best when the hospital, office, or practice has a culture to allow frank and respectful discussions, and there are instilled values of respect, integrity, and caring,” says Luis T. Sanchez, MD, director at Physician Health Services, Inc., a corporation of the Massachusetts Medical Society.

Hash it out at least twice

If at all possible, the staff members involved should resolve the problem themselves, although Bartholomew says research shows healthcare professionals rarely do so.

“We are not known in the healthcare profession, on any level, for confronting each other, and we have to learn how to do that better,” Bartholomew says.

Before going to high-level administration to address a conflict, parties should try to resolve the matter on their own at least twice, Bartholomew says, adding that if you get administration involved, it’s like “running to mother” when there is a problem.

“You want to create an atmosphere where people are responsible for their own behavior, where you invite, encourage, and expect everyone to take care of their own world, to be honest in that world, and to treat everyone as they would their own family member, including the patient,” Bartholomew says.

How the problem is brought up is also important. The first rule is to avoid any kind of aggressive behavior. Bartholomew suggests having the parties involved sit down and describe the situation and its effect on them and the facility.

“Ask for what you need and describe the consequences if the behavior does not change,” Bartholomew says. “What usually happens is that these become hallway conversations, and they are high-strung.” (See “Conflict-reducing techniques” on p. 7.)

Although you want to encourage everyone to resolve their conflicts and problems, nurses will likely be hesitant when there is a problem with physicians, Bartholomew says, adding that although physicians expect nurses to come to them with their concerns, nurses are reluctant to do so. It takes a lot of courage for a nurse to approach a physician, and physicians do not realize this power difference, she says.

“You’re talking about nurses, many of which have two-year degrees and an eight-year gap in education in many places—it’s intimidating,” Bartholomew says. “And their experiences have shown them that it is intimidating to approach a physician. Even though research shows there are only a few disruptive doctors, it also shows an exponential amount of damage. Don’t let one bad apple spoil the bunch.”

Call lawyers as a last resort

If the problem escalates to issues such as sanctions or threats of termination, the facility may want to consider contacting its attorney.

“Attorney involvement can be very helpful in resolving the problems,” says Sanchez.

But Bartholomew suggests that lawyers be used only as a last resort. “You’d have to have pretty ineffective leadership and very poor confrontation skills,” she says. “The situation only escalates to a legal mess when it is allowed to continue and fester for a long period of time.”

It often helps to have rules written into the organization’s bylaws that outline what is acceptable and unacceptable behavior.

Create ‘rules for peace’

“You’re expected to be a team player; you’re expected to communicate with respect,” Bartholomew says. “You have to have these standards written into your annual evaluations and your performance evaluations. You don’t want the rules for the fight—you want rules for peace.”

Sanchez adds that the rules need to reflect that the organization promotes a communicative atmosphere when it comes to staff relations and conflict. “Rules are okay if coupled with an atmosphere of collegiality, discussions, time allowed to do this, and best if fully supported and demonstrated by the boss,” he says.

Open lines of communication between staff members in times of conflict are important to maintain quality patient care, Bartholomew says.

“When you have everybody working as a team, you have a lot of energy available to your facility,” she says. “If you have two people that are fighting all the time, it is diverting the energy and focus away from the real job of your facility, which is to provide great patient care.”



Adapted from The Doctor’s Office, February 2009, HCPro, Inc.



Nursing Leadership Summit

Celebrate the image of nursing

Award ceremony will recognize nurse leaders’ and staff members’ positive reflections

Since Shelley Cohen, RN, BS, CEN, president of Health Resources Unlimited, a healthcare education and consulting company in Hohenwald, TN, took her first steps in the nursing profession more than 30 years ago, more has changed than the stark white uniform.

“Gloves were unheard of, we smoked at the nursing station, and the more blood you had on yourself at the end of your shift meant you were a better ED nurse,” says Cohen. “We never once thought anything about what we said or did—and about how we affected our image.”

But nurses today must be aware that their actions and behavior signify their professionalism and education, and thereby positively or negatively shape their image and the nursing image as a whole.

Nurses must continuously strive to improve this image, says Cohen.

“As the healthcare delivery system changes, patient and family expectations are going to change,” Cohen says. “Nursing cannot afford to stay stagnant as a profession, and the nursing image needs to reflect the current trend in delivering patient care.”

Those who elevate the image of nursing within their facilities and inspire others to do the same should be celebrated, which is the idea behind HCPro’s 2009 Nursing Image Awards, to take place in September.

“It’s about time nurses recognize each other for all that they do,” says Cohen, who is one of the judges for the awards that will be handed out at HCPro’s Nursing Leadership Summit in Boston. “This is an opportunity to stand proud for all that the profession brings to patient care.”

Awards are being presented to an individual or team of nurses and to a nursing leader. There are two categories:

  • The image of nursing in clinical practice. This category recognizes individual nurses or nursing teams who portray a positive image of nursing through their clinical excellence and who have made significant contributions to improve patient outcomes, patient safety and quality initiatives, staff satisfaction, practice changes, research or evidence-based practice projects, interdisciplinary collaboration, or organizational goals.
  • The image of nursing in leadership. This category honors a nursing leader who embodies a positive image of nursing through his or her leadership excellence. This individual will have served as an inspiring leader, mentor, and role model to nurses in an effort to portray an image of professionalism, whether by overcoming significant challenges, spearheading change, or inspiring teamwork that resulted in achievement of operational goals and objectives.

Award winners will be honored for elevating the image of nursing and recognized in HCPro’s national nursing publications, as well as at the Nursing Leadership Summit. The awards will be well deserved, Cohen says, and well received. “The nursing image may have been different [before], but one thing that hasn’t changed is the pride that comes with the profession,” she says.

Editor’s note: The deadline for HCPro’s 2009 Nursing Image Awards nominations is May 31. For more information about the awards and to submit nominations, visit For more information and to reserve your spot at the 2009 Nursing Leadership Summit being held September 21–22, visit



Patient care

Enhanced system assessments improve patient flow

After reading this article, you will be able to:

  • Identify the areas in which hospitals can focus performance improvement efforts
  • Describe a flow sheet one facility created to improve patient flow

Poor patient flow affects patient care, safety, and satisfaction. Patients often face obstacles to quick and efficient care at multiple stages of their stay, from triaging in the ED to getting a bed in the inpatient unit to being discharged at the appropriate time.

But the daunting process involves multiple staff levels, departments, and documentation requirements. Where exactly do you start making performance improvements?

The first step is figuring out where to begin and focus your efforts, a step many hospitals tend to skip, says Derenda Pete, RN, MBA, senior accreditation consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

“One of the common mistakes is not taking a very good assessment of the patient process from the time they enter the emergency department until they are discharged from the hospital,” Pete says.

Without a thorough assessment, you can’t know where a hospital’s patient flow troubles lie. Although an assessment may take time, it gives hospitals the most return on their performance improvement efforts.

“Make it very simple,” says Pete. “Decide what to focus on and what that one or two—not 10—metrics need to be in order to show performance improvement. And make sure performance is reported to leadership in regular intervals.”

Pete cites three main problem areas in hospitals:

  • Timely physician evaluation of ED patients
  • Quick movement of patients to inpatient units
  • Appropriate discharge of patients

The latter two are the responsibility of the inpatient unit, says Pete, adding that ensuring free beds in the inpatient units is critical to avoiding a crowded ED and potential patient safety issues.

“Whenever you reach or exceed your functional capacity, your potential for a sentinel event increases tenfold because there’s limited staffing and resources,” says Pete. “Things just don’t get done. Patients and documentation may be overlooked. … Efficient care is that much harder, effectively slowing down discharges.”

And patients may end up staying more days than what is truly required.

Focus on inpatient care

Every hospital must assess and determine specific areas on which to focus improvement efforts, but Pete says getting ED patients to inpatient beds should be a priority.

“The issue is that the ED is ready to get the patients upstairs, but they stay put because there are no beds available,” says Pete. A full inpatient department may be due to any number of reasons including staffing issues, inappropriate use of resources, long physician response times, and various discharge issues, which should all be part of the initial assessment.

“You’re not going to be able to improve everything,” Pete says, adding that the process will be a collaborative effort. Still, inpatient care should not be overlooked as a patient flow issue.

“One of the common things I hear … is that once patients get into the inpatient unit, things slow down,” says Pete. “Hospitals need to have care plans set up to treat common diagnoses on their units.”

Establishing these care plans and knowing where the variances lie will help patients get the